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The nurse is caring for a patient who is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serological testing is negative for viral causes of hepatitis. Which of the following questions by the nurse is best?
- A. Is there any history of IV drug use?
- B. Are you taking corticosteroids for any reason?
- C. Do you use any over-the-counter (OTC) drugs?
- D. Have you recently travelled to a foreign country?
Correct Answer: C
Rationale: The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen. Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.
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Which of the following nursing actions is a priority when the nurse is caring for a patient with pancreatic cancer?
- A. Offer high-calorie, high-protein dietary choices.
- B. Offer psychological support for anxiety or depression.
- C. Educate about the need to avoid scratching pruritic areas.
- D. Administer prescribed opioids to relieve pain as needed.
Correct Answer: D
Rationale: Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education, or manage anxiety or depression.
Which of the following data obtained by the nurse during the assessment of a patient with cirrhosis is of most concern?
- A. The patient's hands flap back and forth when the arms are extended.
- B. The patient has ascites and a 2-kg weight gain from the previous day.
- C. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
- D. The patient complains of right upper-quadrant pain with abdominal palpation.
Correct Answer: A
Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurological status.
Which of the following nursing actions should be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade using a device such as a Blakemore tube?
- A. Monitor the patient for shortness of breath.
- B. Encourage the patient to cough every 4 hours.
- C. Deflate the gastric balloon every 12 hours.
- D. Verify the position of the balloon every 6 hours.
Correct Answer: A
Rationale: A common complication of balloon tamponade is occlusion of the airway by the balloon, so it is important to monitor the patient's respiratory status. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8-12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.
The nurse is caring for a patient who is diagnosed with acute hepatitis B. Which of the following information should the nurse include in the teaching plan?
- A. Ways to increase exercise and activity level
- B. Self-administration of ?±-interferon
- C. Adverse effects of nucleoside and nucleotide analogs
- D. Measures that will be helpful in improving appetite
Correct Answer: D
Rationale: Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for persistent hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.
A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, which of the following serological findings should the nurse expect?
- A. Antibody to hepatitis D virus (anti-HDV)
- B. Hepatitis B surface antigen (HBsAg)
- C. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
- D. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
Correct Answer: D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.